What You Need to Know About Borderline Personality Disorder - Part ll

You have been diagnosed with bipolar disorder. Perhaps it was ten days ago, perhaps it was ten years ago. You have been put on a mood stabilizer or an antipsychotic or maybe both. Your psychiatrist is happy because you are no longer a 911 case waiting to happen. You are miserable because you can’t hold down a job, you alienate everyone you come into contact with, and you very rarely experience that sublime state of contentment we call peace of mind.

What is wrong?

Standard procedure is for your psychiatrist to tinker with your meds. But what if the diagnosis is wrong? Or incomplete?

For many of us, this is deja vu all over again. We’d been through something like this with a misdiagnosis of clinical depression and failed trials on antidepressants. A lot of us actually felt relieved to have our diagnosis upgraded to bipolar. Surely, with the right diagnosis and the right meds our lives would improve.

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But little or nothing has changed. What could be wrong?

This may be time to consider the prospect of borderline personality disorder. The issue may not be as simple as substituting one diagnosis for the other. Some of us - about 20 percent - may have both illnesses going on at once. Or, if we think of borderline as pneumonia which some of us may have, there is still the small matter of that universal common cold known as personality issues.

These personality issues may barely rate clinical consideration, but if unaddressed they may represent the true obstacles standing in the way of our recovery. To the extent that we all have personality issues, there is no true us vs them.

First, let’s investigate the pneumonia:

The DSM sheds very little light on the distinctions between borderline and bipolar. The impression one gets is two different teams of psychiatrists describing the same clinical phenomenon slightly differently. Seven of the nine symptoms listed for borderline - at first blush - appear to be virtually interchangeable with depression or mania. Thus:

Unstable self-image or sense of self (for comparison, the DSM for depression lists feelings of guilt and low self-worth, while grandiosity features in mania).

Impulsivity, such as in engaging in “damaging” behavior (for mania, the DSM lists “reckless” behavior, with spending and sex cited as examples on both lists).

Reactive affective instability (in other words, mood swings, but with a clear cause and effect).

Recurrent suicidal behavior (also part of the DSM depression checklist). Chronic feelings of emptiness (compare to feelings of worthlessness and inappropriate guilt in depression).

Inappropriate and intense anger (the DSM cites irritability in hypomania and in mixed manias, with a strong case to be made for anger-driven depressions).

Transient stress-related paranoia or disassociation (on the surface, this may resemble psychosis, which features in depression and mania).

It would take a brave clinician to make a borderline call based on these seven symptoms alone. Typically, they seek out one of two diagnostic tie-breakers, starting with:

Frantic efforts to avoid real or imagined abandonment. So are we simply talking about bipolars who hate getting dumped? Not really. These are people who may go to pieces when their therapist signals that time is up at the end of an appointment. Clearly, something is amiss.

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Then there is the issue of unstable and intense relationships (alternating between extremes of idealization and devaluation). It’s not like bipolars don’t experience unstable relationships, either, but the idealization/devaluation dynamic adds a whole new twist. Nearly all of us have been on the receiving end:

We meet someone. We hit it off. In the eyes of that someone, we are wonderful, we can do no wrong. Naturally, we feel that we have finally connected with an individual who truly understands us. Then, one day, things unaccountably change. That someone begins to find fault with us. Next thing, we’re the Devil Incarnate. Next thing, we are being subjected to unpredictably outrageous behavior and abuse.

What happened? we can only wonder.

Now, on reflection, we begin to see that there is something more to those so-called “mood” symptoms than just mood, that cannot simply be explained away as bipolar or depression. The phenomenon we are dealing with may quack like a duck, but - clearly - it isn’t a duck.

The borderline experts are very good at providing explanations, but it was only after listening to a different type of expert - namely a patient - that a lightbulb went off.

The occasion was the 2006 NAMI national convention that featured a patient on the panel at an ask the doctors session devoted to borderline. “Anne” was very smart and personable, with a degree in creative writing, but the best job she could get was answering phones.

Those who live with individuals with borderline describe the experience as akin to walking on eggs. By contrast, Anne compared her dealings with people to "walking on shifting boards." The world is far from a safe place, she related, and the ground beneath her could collapse any second. When that happens, she went on to say, something inside of her so overwhelms her that she loses it. Or she reacts by immediately changing her situation. Sometimes slitting her wrists does it for her. Other times, it may be impulsive sex.

Clearly, this is a world far different than the one bipolars occupy. We are talking about an environment they perceive as threatening and unpredictable, even when they try to fashion it and the people in it as rosy and wonderful. We may see those with borderline as emotionally volatile and unstable. In truth, that is how the earth and every person on it appears through borderline sensibilities.